That last sentence sums it up for me; "...an accumulation of numerous small acts of omission." It's not that the staf are actively malevolently bad, but the lack of skill, or the lack of thought, or the lack of the application of the skills brings hurt to the patients. The problem of the water bottle being laid out, but being out of reach is sadly all too common. It's all to easy for staff to assume even elderly patients have the same level of mobility as they do.